eMedicine Specialties > Orthopedic Surgery > Systemic Diseases

Osteoporosis: Differential Diagnoses & Workup

Author: Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery
Coauthor(s): Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Contributor Information and Disclosures

Updated: Apr 30, 2009

Differential Diagnoses

Myeloma

Other Problems to Be Considered

Bony metastases
Multiple myeloma
Primary hyperparathyroidism
Secondary hyperparathyroidism
Osteomalacia
Renal osteodystrophy
Paget disease of bone

Workup

Laboratory Studies

  • Laboratory studies should be used to assess for underlying causes of osteoporosis.
    • Thyroid-stimulating hormone (TSH): Thyroid dysfunction has been associated with osteoporosis and should, therefore, be ruled out.
    • Intact parathyroid hormone (PTH): An intact PTH level is essential in ruling out hyperparathyroidism. An elevated PTH level may be present in benign familial hypocalciuric hypercalcemia (FHH).
    • Calcium: Calcium levels can reflect underlying disease states. Severe hypercalcemia may reflect underlying malignancy or hyperparathyroidism. In addition, hypocalcemia can contribute to osteoporosis.
    • Twenty-four–hour urinary calcium levels: Urinary calcium levels help to rule out benign FHH, in which urinary calcium levels are low.
    • Celiac sprue panels: Celiac sprue has been associated with approximately 5% of osteoporosis cases.
    • Bone alkaline phosphatase: Bone alkaline phosphatase can be mildly elevated in patients with fractures. In addition, patients with hyperparathyroidism, Paget disease, or osteomalacia can have elevations of bone alkaline phosphatase.
    • Serum and urine immunoelectrophoresis: Serum and urine immunoelectrophoresis are used to exclude the presence of multiple myeloma.
    • Urinary N-telopeptide (NTX): NTX, a marker of bone resorption, should be measured. Elevation of this value (>40 nmol bone collagen equivalent per mmol urinary creatine) indicates a high turnover state. NTX levels may also be used to monitor responses to antiosteoporotic treatments.
    • 25-Hydroxyvitamin D and 1,25-hydroxyvitamin D levels: Abnormalities in 25-hydroxyvitamin D and 1,25-hydroxyvitamin D can reflect liver disease and renal disease such as renal osteodystrophy. Inadequate vitamin D levels can predispose persons to osteoporosis.

Imaging Studies

  • Radiographic findings can suggest the presence of osteopenia, or bone loss, although they cannot be used to diagnose osteoporosis. Using the second metacarpal or the metaphysis of a long bone, the sum of the cortical width should be at least equal to the medullary width. Osteopenia is suggested by a sum that is less than the medullary width. In addition, 30-40% bone loss must occur before osteopenia is detected on plain radiography.
  • CT scanning may be useful in identifying fractures. CT scanning can be used to identify not only the fracture line but also areas of callus formation and sclerosis, consistent with healing fracture.
  • MRI may be useful in identifying fractures. Using fat suppression sequences, marrow edema consistent with fracture may be noted as areas of hypointensity on T1-weighted images in association with corresponding areas of hyperintensity on T2-weighted images. MRI is a very sensitive modality and is believed by some to be the first diagnostic imaging method of choice in the detection of acute fractures, such as sacral fractures.
  • Bone scanning may be used to identify the presence of multiple osteoporotic fractures. Areas of increased radioactive tracer uptake represent areas of fracture.

Other Tests

  • Bone mineral density studies should be performed with the use of dual energy x-ray absorptiometry (DEXA). DEXA has been shown to be the criterion standard in assessing bone mineral density. In turn, bone mineral density has been shown to be the best indicator of fracture risk. Bone mineral density may also be measured using calcaneal ultrasonography and quantitative CT scanning. DEXA and quantitative CT scanning measure bone mineral density in both the lumbar spine and peripheral sites. Ultrasonography cannot be used for monitoring skeletal changes over time or in evaluating response to therapy.

Procedures

  • Bone biopsy: In situations in which an unexplained recurrent fracture exists in the setting of appropriate antiosteoporotic medical treatment, bone biopsy may be performed. Bone biopsy can help to exclude underlying pathologic conditions such as multiple myeloma, which may be responsible for presumed osteoporotic fracture. Typically, iliac crest biopsy is performed either in the minor procedure suite or in the operating room. One may also perform a vertebral body bone biopsy when performing a therapeutic procedure such as kyphoplasty (see Image 2).
Osteoporosis. Lateral radiograph demonstrates mul...

Osteoporosis. Lateral radiograph demonstrates multiple osteoporotic vertebral compression fractures. Kyphoplasty has been performed at one level.

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Osteoporosis. Lateral radiograph demonstrates mul...

Osteoporosis. Lateral radiograph demonstrates multiple osteoporotic vertebral compression fractures. Kyphoplasty has been performed at one level.




Osteoporosis. Lateral radiograph of the patient s...

Osteoporosis. Lateral radiograph of the patient seen in Image 1 following kyphoplasty performed at 3 additional levels.

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Osteoporosis. Lateral radiograph of the patient s...

Osteoporosis. Lateral radiograph of the patient seen in Image 1 following kyphoplasty performed at 3 additional levels.


More on Osteoporosis

Overview: Osteoporosis
Differential Diagnoses & Workup: Osteoporosis
Treatment & Medication: Osteoporosis
Follow-up: Osteoporosis
Multimedia: Osteoporosis
References
Further Reading
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References

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  14. [Best Evidence] Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. Mar 23 2009;169(6):551-61. [Medline].

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  28. Agency for Healthcare Research and Quality. Fracture Prevention Treatments for Postmenopausal Women with Osteoporosis. AHRQ: Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=sg&DocID=95&ProcessID=8. Accessed January 30, 2009.

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Further Reading

Clinical guidelines

Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.].  2005 Jan.  51 pages. [NGC Update Pending] NGC:005419

ACR Appropriateness Criteria® osteoporosis and bone mineral density. American College of Radiology - Medical Specialty Society.  1998 (revised 2007).  12 pages.  NGC:005990

Diagnosis and treatment of osteoporosis. Institute for Clinical Systems Improvement - Private Nonprofit Organization.  2002 Aug (revised 2008 Sep).  67 pages.  NGC:006738

Physician's guide to prevention and treatment of osteoporosis. American Academy of Orthopaedic Surgeons - Medical Specialty Society
American Academy of Physical Medicine and Rehabilitation - Medical Specialty Society
American College of Obstetricians and Gynecologists - Medical Specialty Society
American College of Radiology - Medical Specialty Society
American College of Rheumatology - Medical Specialty Society
American Geriatrics Society - Medical Specialty Society
American Medical Association - Medical Specialty Society
International Society for Physical Medicine and Rehabilitation - Medical Specialty Society
National Osteoporosis Foundation - Disease Specific Society
The Endocrine Society - Disease Specific Society.  1999 (revised 2003 Apr).  37 pages.  NGC:003073

Related eMedicine topics

 Hip Fracture

Idiopathic Scoliosis

Intertrochanteric Hip Fractures

Subtrochanteric Hip Fractures

Vertebroplasty and Kyphoplasty, Percutaneous

Clinical trials

 Randomized Trial of Osteoporosis Intervention Strategies in Hip Fracture Patients

Strategies to Treat Osteoporosis Following a Fragility Fracture

Osteoporosis Choice Decision Aid for Use of Bisphosphonates in Postmenopausal Women

Patient- and Physician-Based Osteoporosis Education

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Keywords

osteoporosis, porous bones, weak bones, metabolic bone disease, hip fracture, vertebral compression fracture, dowager hump, dowager's hump, scoliosis, collagen defect, bone fragility, decreased bone mass, decreased bone mineral density, decreased BMD

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Contributor Information and Disclosures

Author

Julie Lin, MD, Assistant Professor, Department of Rehabilitation Medicine, Weill Medical College of Cornell University; Assistant Attending Physiatrist, Physiatry Department, Hospital for Special Surgery
Julie Lin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph M Lane, MD, Professor of Orthopedic Surgery, Weill Medical College of Cornell University; Chief, Metabolic Bone Disease Service, Hospital for Special Surgery
Joseph M Lane, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of University Professors, American Federation for Aging Research, American Orthopaedic Association, American Society for Bone and Mineral Research, Association of Bone and Joint Surgeons, Medical Society of the State of New York, Musculoskeletal Tumor Society, National Osteoporosis Foundation, North American Spine Society, and Orthopaedic Research Society
Disclosure: P & G; Roche; Lilly: Aventis: Novartis: Spinewave; biomimetics; Zimmer; DFine; Innovative Solutions; Honoraria Speaking and teaching

Medical Editor

Miguel A Schmitz, MD, Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jerome D Wiedel, MD, Chair, Professor, Department of Orthopedics, University of Colorado Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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